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Assessing effectiveness of a vancomycin continuous infusion protocol within the intensive care units (ICUs) at a London tertiary-care hospital: a single-centre retrospective service evaluation
Abstract
Background
Appropriate vancomycin dosing and therapeutic monitoring is important to optimise treatment. In St George’s Hospital ICUs, non-renal replacement patients receive a loading dose (<65 kg, 1000 mg; ≥65 kg, 1500 mg), alongside a maintenance continuous infusion based on creatinine clearance (CrCl) and daily serum levels (target therapeutic range 20-25mg/L). As non-therapeutic levels can negatively affect clinical outcomes, a service evaluation was conducted.
Methods
Electronic prescribing data (vancomycin doses, serum levels, biochemistry, and demographics) within a 66-bed ICU service were reviewed retrospectively (July 2020–July 2021). Cockcroft-Gault CrCl was calculated using total body weight (TBW), or adjusted body weight in obese patients. Patients receiving appropriate vancomycin loading/maintenance doses were analysed.
Standards
1. Proportion of patients therapeutic and supra/sub-therapeutic within 48-hours
2. Time taken for non-therapeutic patients to become therapeutic
Results
Patients (n=54, 79.6% male, mean age 59.9±13.9 years) received continuous vancomycin infusions. Their TBW was 84.5±17.0 kg. Median CrCl was 59.1 (inter-quartile range 43.1-123.5) mL/min (n=47). The protocol-recommended loading dose equated to 17.8±3.0 mg/kg TBW. Vancomycin levels within 24- and 48-hours were 19.5±9.9 mg/L (n=17) and 21.0±6.7 mg/L (n=15); 7/17 (41.2%) and 3/15 (20.0%) were in therapeutic range, respectively. By 48-hours, 46.7% (7/15) were sub-therapeutic and 33.3% (5/15) supra-therapeutic. Vancomycin levels for patients with CrCl>50mL/min and CrCl<50mL/min were 17.9±7.2 mg/L (8/15) and 24.5±4.2 mg/L (7/15). After dose adjustments, non-therapeutic patients became therapeutic in 3.9±1.0 days (n=7)
Discussion
Compliance to and dosing of the current vancomycin protocol requires review to ensure therapeutic levels are achieved more rapidly and consistently, whilst minimising toxicity.
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Aims:
To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.
Methods:
This multicentre, prospective, observational study reviewed participants' data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants' notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence.
Results:
In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06).
Conclusions:
Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers. This article is protected by copyright. All rights reserved.